From a community outreach representative at a community centre, library, daycare, hospital, etc.

From a poster/ brochure in the community

Online (eg. Facebook)

From an internet search engine

Other

Please Specify

Child Info

Child's Name*

FirstLast

Child's Gender*

Male

Female

Child's Birth Date*

Language Exposure*

Language 1 (%)

Language 2 (%)

Language 3 (%)

Language 4 (%)

EXAMPLE: English (80%) and Spanish (20%).

Please indicate the languages that your child is exposed to on a regular basis. Please also indicate approximately how much of each language your child is hearing. For example, if your child is hearing 80% English and 20% Spanish, you would enter English (80%) in the first column and Spanish (20%) in the second column.

Was your pregnancy full term?*

Yes (full term)

No (premature)

Gestation Period*

Weeks

Days

Please indicate the length of your pregnancy (gestation period) in weeks and days. For example, 34 weeks and 4 days.

Do you have any other children?*

Yes

No

Would you be interested in participating with your other children, too?*

Yes

No

Additional Child Info

Child's Name*

FirstLast

Child's Gender*

Male

Female

Language Exposure*

Language 1 (%)

Language 2 (%)

Language 3 (%)

Language 4 (%)

Please indicate the languages that your child is exposed to on a regular basis. Please also indicate approximately how much of each language your child is hearing. For example, if your child is hearing 80% English and 20% Spanish, you would enter English (80%) in the first column and Spanish (20%) in the second column.

Child's Birth Date*

Was your pregnancy full term?*

Yes (full term)

No (premature)

Gestation Period*

Weeks

Days

Please indicate the length of your pregnancy (gestation period) in weeks and days. For example, 34 weeks and 4 days.

Would you like to add another child?*

Yes

No

Additional Child Info

Child's Name*

FirstLast

Child's Gender*

Male

Female

Language Exposure*

Language 1 (%)

Language 2 (%)

Language 3 (%)

Language 4 (%)

Please indicate the languages that your child is exposed to on a regular basis. Please also indicate approximately how much of each language your child is hearing. For example, if your child is hearing 80% English and 20% Spanish, you would enter English (80%) in the first column and Spanish (20%) in the second column.

Child's Birth Date*

Was your pregnancy full term?*

Yes (full term)

No (premature)

Gestation Period*

Weeks

Days

Please indicate the length of your pregnancy (gestation period) in weeks and days. For example, 34 weeks and 4 days.

Would you like to add another child?*

Yes

No

Additional Child Info

Child's Name*

FirstLast

Child's Gender*

Male

Female

Language Exposure*

Language 1 (%)

Language 2 (%)

Language 3 (%)

Language 4 (%)

Please indicate the languages that your child is exposed to on a regular basis. Please also indicate approximately how much of each language your child is hearing. For example, if your child is hearing 80% English and 20% Spanish, you would enter English (80%) in the first column and Spanish (20%) in the second column.

Child's Birth Date*

Was your pregnancy full term?*

Yes (full term)

No (premature)

Gestation Period*

Weeks

Days

Please indicate the length of your pregnancy (gestation period) in weeks and days. For example, 34 weeks and 4 days.

Untitled

First Choice

Second Choice

Third Choice

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